Background
Mental, neurological, and substance abuse disorders have been identified as the largest contributors to years lost to disability globally (Whiteford et al. 2013). In low- and middle-income countries (LMICs) where mental health spending averages less than 25 cents per person (WHO 2011), more than 85% of mental health conditions go untreated (Saxena et al. 2007). Outcomes for individuals with mental distress are further complicated by the absence of legislation to protect their human rights, with only 36% of LMICs having mental health legislation (WHO 2013).
Amidst a climate of austerity in both high-income countries and LMICs, interventions promoting empowerment and local action in response to health problems have become increasingly popular (Lowndes and Pratchett 2012), often idealising communities as spaces of potential, shared identity, and common ideals. However, these perspectives can often gloss over the complexities of promoting community engagement—an issue that has been explored extensively in the contexts of community responses to HIV/AIDS in subSaharan Africa. For example, the invisible dimensions of power, position, norms, and conflicting knowledge systems have all been linked to the challenges facing community work within the HIV/AIDS response (Campbell et al. 2008; Campbell and Nair 2014; Campbell 2000; Gibbs and Campbell 2014; Burgess 2013a). Potential impacts of these issues bear relevance beyond HIV/AIDS and carry implications for any health issue being tackled at community level (Campbell and Cornish 2010).
The expansion of a community discourse in the field of Global Mental Health has been driven largely by the Movement for Global Mental Health (MGMH) (see Patel and Prince 2010), whose main interest resides in addressing the gap between the proposed need for treatment and available services in LMICs. Their interest in communities has been linked to community approaches piloted during the first two decades of the AIDS response (Campbell and Burgess 2012) and the wider deinstitutionalisation of mental health services beginning in the 1960s and 1970s. Capacitating local communities to promote self-care through promoting volunteerism and training of lay community health workers has assumed the core of the community engagement framework within global mental health. The publication of a series of grand challenges for global mental health (Patel et al. 2011) confirmed the importance of communities to the movement with two ‘challenges’ explicitly naming ‘community’ as a locus of action:
- 1. Provide effective and affordable community-based care and rehabilitation.
- 2. Support community environments that promote physical and mental well-being throughout life.
Community-based care and rehabilitation have formed the focus of multiple studies and research to identify ‘cost-effective’ mental health interventions delivered by community volunteers and health professionals under the umbrella of ‘task-shifting’ approaches (Kakuma et al. 2011). In this model, community health workers are trained in basic treatment skills to act as appendages to over-burdened or non-existent health systems. Health volunteers are to act as trusted conduits, it is hoped, smoothing relations and the uptake of ideas among local individuals. The second point, promoting supportive community environments, speaks more directly to ideas of social change, and on efforts to ensure that communities (local environments) are places where positive mental health can be maintained.
Theoretically, community-based approaches allow for attention to a wider range of determinants of mental ill health and related responses, which could contribute positively to addressing both of the above ‘grand’ challenges facing the movement. However, given issues faced with implementing community approaches in other health settings (Campbell 2003), how do we develop approaches to ‘community’ mental health in a global context?
